- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,162.28 / $3,548.13
| Facility | | $1,737.80 | $3,162.28 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,348.96 / $1,905.46
| Professional | | $1,148.15 | $1,348.96 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $32.36
| Facility | | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $32.36
| Professional | | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,174.90
| Facility | | $1,122.02 | $1,122.02 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $21.38 / $42.66
| Professional | | $16.98 | $21.38 | $42.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,089.30
| Facility | | $1,548.82 | $1,548.82 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $3,890.45
| Professional | | $724.44 | $1,047.13 | $3,890.45 |